High glycemia in a child or teenager after the diagnosis of Type 1 Diabetes
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Introduction
Your child is critically ill, and doctors do not know what causes this disease or how to cure it. Your child has diabetes. One hundred years ago, these dreadful words were heard by the parents of our patients around the world.
Today, medicine still does not know the exact causes of diabetes, but it has learned to compensate for the damage caused by the disease through the regular administration of artificial insulin. It is a world of difference compared to the times when Frederick Banting had not yet discovered insulin, and the pharmaceutical company Eli Lilly had not started its industrial production. Today, Type 1 Diabetes is still a formidable and frightening diagnosis, but current patients have every chance to live many happy decades and die of old age or completely different causes.
The fear and horror of parents of children with Type 1 Diabetes diminish with the duration of the disease and knowledge about it. However, almost all parents describe the day of diagnosis as the darkest and most terrible day – the day they hear "Type 1 Diabetes." The insidiousness of diabetes lies in the fact that by the time of obvious clinical manifestations, the disease has been progressing for months, destroying the β-cells of the pancreas until there is absolute decompensation of glucose metabolism.
Manifestation of Type 1 Diabetes
During the manifestation period, the classic clinical signs of diabetes become clear and evident:
Thirst
Frequent and abundant urination
Increased appetite accompanied by weight loss
On this background, a complication known as diabetic ketoacidosis can easily develop. This is the result of prolonged high blood glucose levels and the lack of glucose inside the cells. Insulin is necessary for glucose to penetrate the cell membranes. When cells start to starve, they begin breaking down fats and proteins for energy, all the while being bathed in a sweet syrup as the blood plasma turns due to months of high glycemia. All vital processes are disrupted. In this severe state, the child is often rushed to the hospital by ambulance and, in a significant percentage of cases, ends up in the intensive care unit. There, utilizing all available intensive therapy methods such as saline infusions, intravenous insulin administration, proper nutrition, etc., the child is quickly brought out of ketoacidosis and placed in a specialized endocrinology department.
This is indeed a dangerous condition, but at this point, professionals who know what to do and have already managed ketoacidosis in children with the same diagnosis hundreds of times are responsible for your child. The child is then in a department where they are fed a consistent diet with a predetermined amount of carbohydrates. The doctor instructs the nurse on how many units of insulin to administer; the nurse helps the child or measures blood glucose levels themselves; all these numbers are recorded and analyzed by the treating doctor to adjust the dose of exogenous insulin, since the body has almost none of its own. Simultaneously, examinations are conducted to clarify the diagnosis and understand how much the state of decompensation has already damaged internal organs and tissues, in other words, to look for long-term complications.
Criteria for diagnosing diabetes mellitus:
Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L);
or plasma glucose ≥ 200 mg/dL (11,1 mmol/L) two hours after a glucose load (75 g of glucose);
or plasma glucose ≥ 200 mg/dL (11,1 mmol/L) in a random test in the presence of classic signs of hyperglycemia.
It becomes easier, and the glucose numbers in diaries and charts gradually decrease, approaching the desired non-diabetic levels.
Parents are in a state of shock during this time, struggling to absorb the vast amount of information about their child's chronic illness. Meanwhile, they must continue with their everyday lives: earning money and taking care of other children. It is during the initial hospitalization that they attend the diabetes school, where they receive essential knowledge. While in the hospital, it is crucial to ask the attending physician questions about the course of diabetes, prognosis, and practical tips for managing the condition.
Discharge - What to do next?
And so, your child is discharged under the supervision of an endocrinologist at the clinic. You are provided with a glucometer, test strips, a lancet with scarifiers, pens with short-acting and long-acting insulin, spare cartridges with insulin and needles for the pens, a diabetes diary with incomprehensible numbers, and a discharge summary with insulin doses for night and meals. You spend your first night at home, trying to stick to the hospital routine. On the first day, you manage, but after that...
As I write this, I feel the difficulty, even though I don't have a child with diabetes. The feeling of being alone with a huge problem, with no support or guidance, can be overwhelming. The blood sugar on the glucometer is again in double digits before meals, or even 600 mg/dL (33.3 mmol/L), which is the upper limit of many glucometers. All these doses and carbohydrate counts offer no clear guidance. What to do, where to run, whom to call?
Dear parent, you are at a turning point after which everything will definitely get better! You will learn more about your child's disease, glucose levels will decrease, you will confidently manage and compensate blood sugar in most cases, and isolated instances of decompensation will not throw you off balance. Life happens.
It is crucial to find psychological support after discharge from the hospital. This could be a psychologist, an endocrinologist, or a fellow parent of a child with diabetes. As hard as it may be to believe now, once you get through the stress and despair of the first months, you will be able to help other parents whose children start their fight against diabetes later, aiming for a long and happy life.
Let us hope that in the coming years, the long-awaited breakthrough in the treatment of autoimmune diseases, including Type 1 Diabetes, will occur. In the meantime, we are seeing a rise in diabetes overall and Type 1 Diabetes in particular.
As of 2023, according to IDF (International Diabetes Federation), there are approximately 540 million adult people worldwide living with diabetes, including 8.75 million with type 1 diabetes (T1D).
So, 0.11% of the entire world population have Type 1 Diabetes (T1D), which is 1 person out of 1000. In a filled subway car there are approximately 330 people, this means that in 3 subway cars, there is a person suffering from T1D.
Compensating glycemic levels becomes more difficult the younger the child and the shorter the diabetes duration, with the exception of the puberty period. Later on, you will know your child's diabetes better than the endocrinologist, as an adult's metabolism will become more stable and predictable for calculating doses. For now, let's stick to simple algorithms. First, we will learn to add and multiply, and later we will get to advanced math.
It will get easier! And I don't rule out the possibility that you will learn to coexist peacefully with diabetes – who knows, you might even become friends with it. For now, it's important to win this particular battle, but even a loss in it is not a loss in the war against diabetes. Diabetes will be with your family for life; hyperglycemia will be the most frequent problem faced by parents and then by the patient themselves, but it is not the most frightening one. It is the most common situation, fortunately not requiring urgent action, leaving time to think.
Hyperglycemia
High blood glucose (hyperglycemia) existing for several hours will not lead to acute complications; a longer period of time is required for that. In this regard, Type 1 Diabetes behaves more "decently" than Type 2 Diabetes in adults. Recall the debut of your child's diabetes and the level of glycated hemoglobin, which shows the average blood glucose level over the past three months. Before decompensation began, blood glucose levels were high for weeks! You have time to think about what and how to do best in a hyperglycemia situation.
You are not alone. Of course, until the child realizes the risks of long-term complications and the consequences of neglecting the doctor's recommendations, the responsibility for compensation lies entirely with you. It is useless to torment the child with your fears and excessive control; they are already stressed from endless injections and food restrictions. Do not scold them if they forget to measure, record, or think, especially in the beginning. You are the commander who leads comrades and allies in the fight for disease compensation: the other parent, grandparents, other family members, teachers at school, and coaches in sports clubs – in general, all adults who care about the child's well-being, gathering information and carrying out your compensation decisions.
You have the contacts of the department where you were treated, your attending physician, the doctor who led the diabetes school, and the diabetes hotline. You may already be registered on forums and in groups of parents of children with Type 1 Diabetes. There are qualified and experienced participants who can provide competent advice. But please, when asking "how much insulin to inject," you should inform the respondent of all important information about the child, their blood glucose levels, your actions up to that point, and usual insulin therapy doses. To provide this information, you need to know it. It should be recorded on a piece of paper, in a program, or on your phone.
Sequence of Actions for Hyperglycemia
Measure blood glucose
Observe its high level
Analyze the information
Administer the calculated dose of ultra-fast insulin to lower it
Measure blood glucose after one hour at the peak action of insulin
Analyze the information
Measure blood glucose after two hours
Analyze the information
That is it if the glycemia is acceptable,
Or administer an additional calculated dose if you administered too little insulin (enter the cycle again)
Or consume 5 - 10 grams of fast-acting carbohydrates if you administered too much insulin (check glycemia again in half an hour when the carbohydrates have appeared in the blood)
If something illogical happens with the blood glucose level, remeasure it.
You managed it, but until all the information is recorded, documented, and analyzed, the episode is not over! Analyzing similar cases and numbers will help you calculate the dose correctly next time.
If there are no similar situations in your diary, you should follow the discharge instructions, which should include the insulin therapy regimen and the insulin sensitivity factor (ISF) – the amount by which 1 unit of insulin lowers blood glucose levels in mg/dL for your child. Children have a wide range of ISF, and it can vary even between morning and evening hours for the same child! Generally, 1 unit of ultra-fast insulin can lower blood glucose by 180-220 mg/dL in a child. Insulin pens typically have a step of 0.5 or 1 unit, so it’s important to know your child's specific ISF to avoid a cycle of constant measurements, injections, and snacks.
Consider the nuance that can be easily overlooked, especially during stress. Unfortunately, technical malfunctions of the glucometer or insulin pen can occur; insulin can spoil (due to improper storage); or the insulin injection site might be chosen incorrectly (insufficient subcutaneous fat layer, lipomas in frequent injection sites), etc. Therefore, it is crucial to have backup supplies: a second glucometer with test strips for verification, calibration strips, new insulin pens; and to know and regularly change injection sites.
Insulin Pumps
Another important question for parents is why endocrinologists do not immediately recommend insulin pump, even though it is the most advanced method of managing Type 1 Diabetes in children. Statistically, the level of compensation on pump insulin therapy is better than on basal-bolus insulin therapy with pen injectors.
Basal-bolus insulin therapy involves a regimen where long-acting insulin meets the body's insulin needs between meals, while ultra-fast insulin controls blood glucose after meals. In pump insulin therapy, there is no long-acting insulin; instead, there is a continuous delivery of the same ultra-fast insulin in microdoses (basal rate). This mimics the natural background secretion of insulin and replaces the use of long-acting insulin. However, an insulin pump is a high-tech programmable electronic device, which, in case of malfunction, adds technical complexities for unsure users and reduces decision-making time because there is no long-acting insulin. Ultra-fast insulin breaks down within 3-4 hours, and the body does not produce its own insulin. If rising hyperglycemia cannot be stopped within a couple of hours while on the pump, one must steady their hand, remove the pump, and administer insulin using the "tried and true" pen injector according to the insulin sensitivity factor (ISF). Then, the pump can be dealt with later with the help of an experienced consultant.
Currently, in some countries, the wait time for receiving a free pump in a pediatric department can extend to a year. Undoubtedly, our ultimate goal is a pump with a continuous glucose monitoring sensor, as the best means of compensating for Type 1 Diabetes.